ANTERIOR CAPSULAR SHIFT

Melanie McNeal, PT, CSCS, CFT
for patients of
DAVID LINTNER, MD

This type of surgery is performed on patients with multi-directional instability that is either acquired or congenital. Multi-directional instability (MDI) refers to subluxation or dislocation of the shoulder in three directions – anterior, posterior, and inferior. In surgery, the stretched-out, redundant, ligamentous capsule is incised, tightened, and then sutured back together. Usually, patients with acquired MDI are young, inactive, and generally ligamentously lax. Through repetitive movements that place stress on the anterior-inferior shoulder joint, the capsule is gradually stretched out to the point of impairment. Typical athletes with acquired laxity include swimmers, baseball players, and gymnasts.

The post-op protocol following surgery is based on various factors. Patients with congenital laxity will progress at a slower rate than those with acquired laxity due to the tendency of their ligaments to eventually stretch back out. The therapist should be aware if any other procedures, such as Bankart repair, were performed during surgery and progress as indicated if so. Progression will also vary based on the patient’s tissue status. This should be determined by observing the post-op report or communicating directly with the physician. Pre-op measures including ROM, strength, and stabilization status is another important indication of how rehab will progress. Patients who lacked full ROM and had poor strength measures prior to surgery will be more likely to have difficulties regaining range and strength post-operatively and will progress at a slower rate.
The patient’s functional status must also be considered. Generally, athletes are treated much more aggressively than non-athletes. Overhead athletes are especially progressed at a quicker rate since it is imperative that they regain their full ROM. Conversely, treatment for the general orthopedic patient with generalized laxity must be more conservative. Their goal is adequate ROM in order to fulfill work and everyday activities. The key is achieving balance between having enough range to accomplish these tasks while simultaneously preserving the antero-inferior capsular complex . Usually, it is adequate to only obtain 80-85% PROM with manual techniques with these patients due to their laxity and tendency to stretch out. Because of the different rates of progression for athletes vs. non-athletes, a different protocol should be followed for each.

(Week 1-4)
In phase one, the general goals are to protect the surgical repair, initiate ROM to prevent adhesions and increase circulation, decrease pain and inflammation, and stress emphasis of HEP.

Patients will be placed in either a sling or an immobilizer based on their degree of instability. If placed in a sling, it will usually be worn for 4-6 weeks, including during sleep. The sling can be taken off to perform the indicated exercises. Make sure to consult with the physician regarding the appropriate length of time the patient needs to wear the sling.

Patients with multi-directional instability are usually immobilized anywhere from 4-6 weeks based on the physician’s determination of the stability of the repair and the likelihood of the patient to stretch out again.

The RC gets a better blood supply when the shoulder is slightly away from the body; therefore, advocate the use of a towel roll under the arm when in a resting position.

ROM limitations:

Flexion: 90° until wk 6

Scaption: 60°

ER: 0-15° at 30° abduction wk2

25-30° at 30° abduction wk 4

0° at scapular plane until wk 4

IR at 30°: as tolerated

NO ACTIVE SHOULDER MOTION

Active wrist and elbow full ROM

EXERCISES

ROM

Pendulums

Rope and pulley – flexion to 90°, scaption to 60°

AA cane/wand into flexion, ER at 0° and 30°

Seated or supine posterior cuff stretch into horiz adduction

Grade I-II g-h and scapular joint mobs and manual stretching

Strength: Hand gripping exercises – putty

Submax pain-free isometrics at 0° abduction

Modalities: Heat prior to tx

Ice following tx and when needed

PHASE TWO

(Week 4-6)
General goals in Phase Two are to gradually restore ROM, initiate active muscle contractions with a focus on regaining proper scapulo-humeral rhythm, begin to train joint proprioception, and continue with HEP.

ROM Limitations/goal:

Flexion: to 90° until wk 6

ER/IR at scapular plane wk 5 (25-35° by wk 6)

EXERCISES

ROM

Continue with AAROM exercises from Phase One – pulley, cane/wand

Initiate towel IR stretch if needed

Posterior capsule stretch

G-H joint mobilizations emphasizing post and inf glides. Should be pain-free and in loose/open packed position.

Passive stretching should be performed following mobilizations.

Strength: Scapular stabilizer strengthening – rows, shrugs, punches

IR/ER with theraband using towel roll between upper arm and thorax

Side-step holding t-band at neutral IR/ER for isometric resistance

Biceps, Triceps strengthening

Rhythmic stab progressing from supine to sidelying to partial sitting to standing as tolerated

Modalities: Heat prior to tx

Ice following tx and when needed

PHASE THREE

(Week 6-12)
The goals in this phase are to restore full active ROM, progress strengthening and scapular stabilization exercises, normalize arthrokinematics, and perform HEP.

ROM goals:

Flexion/elevation gradual increase

ER at 90° abduction gradual increase

IR at 90° abduction as tolerated

*Pt should have 80% of their motion by 10 weeks – let them achieve the rest gradually on their own with continued exercise and ADLs.

Full ROM should be achieved by 12-14 weeks!

*The RC muscles are very small; therefore, we use lower intensities to isolate each muscle without recruitment from surrounding larger muscles. Focus on hypertrophy initially by high volume (V= Reps X intensity/weight). Following the hypertrophy phase, strength is the focus with lower reps and higher intensities/weight.

EXERCISES

ROM

Continue with cane/wand, pulley as before

Towel for IR

Progress post cuff stretch and IR stretch to sidelying position

Continue with Grade II and III g-h jt and scapular mobilizations if needed to gain ROM

Dr. David Lintner

Dr. David Lintner specializes in arthroscopic surgery of the knee and shoulder and is active in teaching orthopedic surgeons the latest techniques. He also specializes in injuries to throwers’ shoulders and elbows, having written more than thirty scientific articles about ACL injuries, thrower’s injuries, and other sports medicine issues.

Dr. Lintner is proud to partner with Kirby Surgical Center and provide high quality care and personal attention to our patients. Find more information about Kirby Surgical Center here.